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Case #4

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Expand Physical Exam

05/27/XX

48-year-old male with L upper quadrant pain for a month. Had abnormal CT, IVP, renal nuclear scan at outside facility.

Expand X-Rays & Scans

05/19/XX

CXR normal.

05/20/XX

CT showed large L hydronephrosis and UP junction obstruction. No lymphadenopathy.

05/27/XX

Retrograde cystoscopy: anterior urethra WNL. Prostatic urethra showed mild BPH. Bladder negative. L retrograde ureteropyelogram revealed non-functioning L kidney with ureteropelvic junction obstruction, markedly dilated L pyelocaliceal system, longstanding hydronephrosis.

Expand Operative Findings

05/28/XX

Extensive inflammation of left kidney parenchyma, kidney huge and grapefruit sized. No complications during procedure.

Expand Pathological Reports

05/28/XX

L kidney nephrectomy: high grade papillary urothelial carcinoma of renal pelvis w/extension through muscularis propria into peripelvic adipose tissue. Ureter margin negative. Negative involvement of adrenal, renal vein and artery. No lymph nodes identified.

Expand Treatment

05/28/XX

Surgery: Left nephroadrenalectomy.

07/11/XX

Radiation: Began beam radiation 3000 cGy treatment of renal bed.

07/28/XX

Chemotherapy: Began Chemo – Gemzar, carboplatin.